Diagnosing neurocysticercosis in skeletonized human remains of forensic importance.

Neurocysticercosis is endemic in many parts of the underdeveloped and developing countries, with continuous presence in developed countries due to the influx of migrants from regions where the diseases are endemic. Neuroimaging, anatomic pathological techniques, immunodiagnostic tests, clinical examination and epidemiologic considerations will easily provide the diagnosis. However, physicians in developed countries are perhaps progressively missing the diagnosis, and need to re-acquaint themselves with the condition and acquire a high suspicion index. The authors present a medicolegal case where the forensic team made a conclusion of neurocysticercosis (among other diagnoses), following post mortem examination of a largely skeletonized and mummified human remains. Characteristic changes were observed in the calvarium of the decedent at autopsy. Review of the antemortem medical records revealed that Computed Tomography (CT) scan had 12 years earlier, suggested diagnostic features in a Hispanic migrant, but the attending surgeons failed to consider the possibility of the condition. Physicians should pay attention to suggestive clinical findings especially when attending to individuals coming from endemic parts of the world. Cysticercosis remains endemic and a misdiagnosis can potentially attract medical malpractice suits. Forensic pathologists should also consider the possibility of uncommon clinical disorders, even in skeletonized remains. Perhaps an earlier diagnosis might have altered the outcome in the decedent.

Her-2/neu overexpression in breast cancers in patients of West African extraction seen in Lagos state University Teaching hospital, Nigeria.

INTRODUCTION: Her-2/neu is one of the most important molecular markers of breast cancer. Overexpression of Her-2/neu as evaluated by immunohistochemistry is necessary in the management of breast cancers. This study was performed to determine the proportion of expression of the biomarker amongst breast cancer patients who presented in our 'one-stop breast cancer unit' using automated immunohistochemistry. MATERIALS AND METHODS: Automated immunohistochemical analysis of 107 newly diagnosed breast cancer patients was done for expression of Her-2/neu, between 1st April, 2016 and 30th September, 2018. The data was analyzed using SPSS version 25 for windows and Microsoft excel, 2013. RESULTS: Her-2/neu was overexpressed in 30.1% patients, and it shows no correlation with age and histological grade of the disease. CONCLUSION: There is overexpression of Her-2/neu in our local setting, and this observation is very relevant to any therapeutic decisions and management of these patients.

Completeness and adequacy of clinical and demographic information in non- gynaecologic surgical pathology requisition forms: an analysis of 1046 cases

BACKGROUND: An important cornerstone in health care delivery is the field of surgical pathology and one of its major aims is to provide a complete, precise and comprehensive diagnosis within a short period of time. In achieving this, the clinician needs to properly fill a surgical pathology requisition form.METHOD: All the consecutive requisition forms from January 1, 2018 to April 30, 2018, totaling 1046 were evaluated for completeness of the information. The requesting clinicians were unaware and cytologic smears were excluded. Patient confidentiality was maintained as no names were recorded. All the Information on the forms was recorded as being present or absent. Analysis was done using the Statistical Package for Social Science version 20.RESULTS: Altogether 1046 forms were evaluated and (100%) of the sample population bore the surnames and first names. Ages were recorded in 93.7%. Similarly, 68.2% of the forms did not bear the hospital number. Clinical summary and date of request were absent in 42.9% and 35.4% of the forms respectively. Clinicians name/ signature and investigation required were absent in 25.1% and 21.1% of the forms respectively. Overall, 77.6% of information was provided while 22.4% not provided.CONCLUSION: The names were completely filled in all the requisition forms. Others were incompletely filled. These findings should be communicated to Clinicians and the recurring attitude of allowing House Officers to fill the requisition forms should be discouraged. Efforts should also be made to let Clinicians appreciate the importance of good clinical information since this determines to a large extent the output of laboratory results

A 10 years autopsy-based study of maternal mortality in Lagos State University Teaching Hospital, Lagos, Nigeria.

BACKGROUND: Maternal mortality is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy. Nigeria is among the six countries that record over 50% of all maternal deaths in the world. There are few papers on autopsy based causes of maternal mortality. This paper is to present the causes of maternal mortality that had postmortem done in our center. MATERIALS AND METHODS: This is a 10-year retrospective study of all maternal deaths seen in our center from January 01, 2005 to December 31, 2014. Lagos State University Teaching Hospital is the only state-owned tertiary center and the main referral center in Lagos State. Autopsy records are taken from the death register and other information were extracted from the postmortem reports. RESULTS: Most maternal deaths 98/328 (29.9%) were seen in the age group 26-30 years which was followed by 31-35 years (24.7%). Postpartum hemorrhage was the most common cause of death followed by eclampsia. Direct causes accounted for 60% of maternal deaths with hemorrhage as the most common while cardiovascular related diseases are the most common indirect cause of death. CONCLUSION: The leading causes of death in this study, hemorrhage, cardiovascular disease and eclampsia are highly avoidable and treatable. We recommend that thorough cardiovascular management should be instituted during antenatal care, and the government should focus more on an emergency response such as availability of adequate blood and blood products in the hospitals.

Aetiological significance of alcohol in liver cirrhosis on the Jos Plateau.

Fifty-one patients with histologically diagnosed cirrhosis were studied prospectively over one year period. There were forty-one males and ten females. The majority of patients (75.59%) took alcohol in significant quantity and it was thought to be the most likely cause of the cirrhosis in them. Eighty percent of them had micronodular cirrhosis and 51.3% of them drank only "burukutu" a local alcoholic brew brewed mostly in iron pots and contains two other hepatotoxic agents--aflatoxin and iron. Eight (5.7%) of the patients and five (9.8%) of controls were positive for hepatitis B surface antigen (HBs.Ag). It is likely that alcohol is very important cause of cirrhosis of the liver seen in Jos.

Cervical implant from villoglandular endometrial adenocarcinoma masquerading as cervical villoglandular adenocarcinoma.

This is an unusual presentation of a rare subtype of endometrial adenocarcinoma (villoglandular papillary carcinoma, VGPC) in a 71-year-old woman, which was initially diagnosed on cervical biopsy as being primary cervical VGPC. Loop excision failed to show any evidence of residual disease. Subsequent hysterectomy revealed a localized villoglandular carcinoma involving the uterine fundus and invading the inner one-third of the myometrium, the background endometrium was atrophic. The remaining cervix contained a focus of papillary forming endometrial type adenocarcinoma involving the surface epithelium and the superficial subepithelial glands. In conclusion, VGPC of cervix occurs mainly in young women and can be treated conservatively, pathologists should be cautious in making such a diagnosis in a postmenopausal woman before ruling out a primary endometrial origin.

Medico-legal considerations of deaths from watersports among Caribbean tourists.

Watersports are the dominant recreational sporting activity in the Caribbean islands. The economy of many of these islands is tourist-oriented and millions of tourists take part in such sports annually with some fatalities. A total of 13 watersport-related deaths observed in the Cayman Islands over a 2-year period are presented. Complete autopsies with toxicological and histological studies were carried out in each case. Preexisting cardiovascular disease such as hypertension, coronary artery disease (or relative insufficiency) and cardiomyopathies were observed to be significant risk factors and the mean age at death was 53.7 years. Sudden cardiac deaths predominate. One fatal jet skiing accident also occurred. Tourists are advised to undergo complete medical investigations (including ECG and stress tests) prior to engaging in watersports. Drugs of abuse are to be avoided for medical reasons and insurance considerations. Watersports operators must ensure that their clients complete a medical checklist. All equipment and accessories must be functioning optimally to avoid accidents contributed to by such negligence. Consideration should be given to introducing medical tests prior to signing on their clients and there must be adequate supervision. Some form of governmental regulation and enforceable supervision is necessary.

The skeletonized body: suicidal inhalation of motorbike exhaust.

An adolescent boy who was being treated for psychiatric illness went missing. The body was discovered a year later, and he appeared to have committed suicide by inhaling the exhaust fumes from his motorbike. This report highlights the procedure used for the identification of his skeletonized body and the unusual nature of the source of exhaust fumes.

Fatal compressional injuries from a burst tyre: an industrial death.

A young maintenance man was killed while fixing a heavy duty tyre to a fork lift. The tyre exploded, sprang off the front axle and threw the victim against a wall 7.5 m away, fatally crushing him. Autopsy revealed multiple crush injuries and, cannabinoids were detected in the victim's urine. The mechanism of the fatal pneumatically-induced compressional injuries sustained and the significance of the cannabinoids in the body fluids of the deceased are discussed in this paper. Proposals are given on how to prevent similar accidents in the workplace.

Passive inhalation of cannabis smoke: a novel defence strategy?

Defence lawyers sometimes argue that the presence of cannabinoid metabolites in the defendant's blood or urine resulted from passive unintentional inhalation of environmental cannabis smoke. It would be useful to be able to differentiate passive inhalation from active use so as to discourage the potential abuse of this phenomenon by the defence. Four cases from two jurisdictions in which passive cannabis smoking was used as a defence are presented to illustrate this dilemma. It remains impossible to define objectively an upper limit for blood and urine levels in cases of passive inhalation of cannabis from the environment. However, a claim of passive inhalation, or indeed 'deliberate passive exposure' could be discouraged by making it an offence to place oneself in a position of being 'concerned' in the use of the drug. The onus should be on the defendant to prove that he had not attempted to extricate himself from the situation, being aware of the smoking of cannabis in his immediate vicinity; ignorance would not be an excuse.

CD44 is expressed in hepatocellular carcinomas showing vascular invasion.

CD44 and its variant isoforms are a group of transmembrane glycoproteins which play important roles in immune recognition, in lymphocyte trafficking, and in cell-cell and cell-matrix interactions. Although CD44 is expressed by some normal human epithelial and mesenchymal cells, upregulation of CD44 expression has been related to the metastatic potential of some malignant tumours. In this study of 27 hepatocellular carcinomas (HCCs), an indirect immunohistochemical method was used to investigate the distribution of CD44 in normal liver and to determine whether expression of the standard form of CD44 (CD44s), or two of its variant isoforms (CD44-v3 and CD44-v6), correlated with tumour grade, proliferation indices, or histological evidence of vascular invasion. Fifteen of the tumours were Edmondson grade II, four were grade III, and eight were grade IV. Liver cell dysplasia was present in adjacent liver parenchyma in three cases and vascular invasion was observed in ten HCCs. Vascular invasion was found to be more frequent in high grade HCCs and a significant correlation was observed between tumour proliferation indices and vascular invasion. CD44s was not expressed by epithelial cells of normal liver but was expressed by tumour cells in six HCCs; vascular invasion was present in five of these HCCs. Three CD44s-positive cases also expressed CD44-v3 and two of these also expressed CD44-v6. CD44 was not expressed in areas of hepatocyte dysplasia. There was a significant correlation between CD44 expression and the presence of vascular invasion, but not between CD44 expression and tumour grade or tumour proliferation indices. It is concluded that upregulation of cell surface CD44 expression on malignant hepatocytes is related to their tendency to vascular invasion and may have implications relating to metastasis and prognosis in patients with HCCs.

Inhalation of steaming seafood aroma: sudden death in an asthmatic.

A 29-year-old asthmatic with a family history of atopy inhaled a large dose of fumes from sizzling, steaming seafood being served to another client in a restaurant. She immediately developed respiratory distress, loss of consciousness and cyanosis; she also vomited profusely, aspirated and died with 58 min of the onset of symptoms. Autopsy revealed epiglottitis and tracheobronchitis associated with an infiltration by mast cells. The blood IgE was marginally elevated. Death was attributed to upper respiratory airway obstruction due to aspiration of gastric contents, and to bronchospasm following the inhalation of steaming vapour from the seafood dish. The practice of transporting a platter of sizzling, steaming seafood across dining rooms and restaurants with its aroma permeating the entire premises could prove fatal for atopic customers.

A review of the forensic investigation of scuba diving deaths.

With more people engaging in recreational scuba diving, fatalities from this sport are encountered by forensic investigators. There is a plethora of factors contributing to death and the investigator must be acquainted with how to elucidate them. The emphasis is on a multi-disciplinary approach that involves co-divers and instructors, the rescue team, the police, forensic scientists, diving equipment suppliers, underwater physiologists and physicians, decompression chamber personnel, general practitioners, relatives and the forensic pathologist. This report presents the various factors contributing to scuba diving deaths and suggests how to conduct such investigations.

Suicidal chloroquine poisoning: report of two cases.

Two cases of suicidal chloroquine poisoning are presented. The autopsy, toxicological findings and strategies for preventing self-destruction by this method are discussed.

Suicidal inhalation of vehicular exhaust in the Lothian and Borders region of Scotland.

1. A 6-year retrospective study of the features of 79 consecutive completed suicides from exhaust fume inhalation (SEFI) in the Lothian and Borders region of Scotland was conducted. Full forensic autopsies with histological and toxicological studies were carried out. 2. The mean incidence is 2.0/100,000 population (M = 3.7; F = 0.4; P <> 0.001); increasing since 1990. The age peak is in the 35-44 years age group (especially among males) and a significant (P < 0.001) proportion reside in rural areas. 3. SEFI is significantly (P < 0.05) higher during spring and summer; outdoor locations are prevalent during summer. 4. Most (75.6%) of the victims were in current employment. Psychiatric illness (30.7%), problems in marriage or relationships (28.2%) and financial difficulties (16.7%) were the major associated socio-medical factors. 5. The mean carboxyhaemoglobin (COHb) saturation was 74 +/- 11.2%; fatal COHb saturation levels were still detectable in severely decomposed bodies. The blood alcohol concentration (BAC) in 37 of the victims ranged from 14-397 mg dl-1. No significant correlation exists between COHb saturation and the victim's age or BAC. 6. Attempts to reduce the incidence of SEFI must be directed principally to dealing with associated sociomedical problems. The reduction of the potential of vehicles to produce carbon monoxide and of directing exhaust fumes into the interior of the vehicle are important secondary preventative measures.

Deaths from substance overdose in the Lothian and Borders region of Scotland (1983-1991).

1. A retrospective analysis of 352 consecutive cases of fatal substance overdose that occurred in the Lothian and Borders region of Scotland (LBRS) between 1983 and 1992 (inclusive) is presented. All these cases were subjected to a full forensic autopsy with histological and toxicological studies. 2. The overall male:female ratio is 1.2:1. Males significantly predominate (1.9:1) in the 21-30 year age group, but females significantly predominate (0.7-0.9:1) above the age of 50 years (P < 0.001). A significant progressive alteration in the sex ratio is noted: from 0.7:1 in 1988 to 2.4:1 in 1992 (P < 0.001). 3. Analgesics account for 43.2% of all overdose deaths with narcotic analgesics representing 32.4%. Dextropropoxyphene is the commonest (38.2%) narcotic analgesic and fatal overdoses on it have been increasing since 1989; methadone deaths also showed an increase. Death from heroin overdose fell sharply in 1985. 4. Antidepressants account for 20.2% of deaths (tricyclics representing 19.3%): Amitriptyline is the commonest (75.0%) tricyclic and its use, particularly by female suicides, has been increasing since 1989. Barbiturate poisoning has declined considerably since 1986. 5. Temazepam comprises 65.4% of all benzodiazepines overdose deaths; two-thirds of fatal benzodiazepine abuse involve males. 6. This study once more emphasises that physicians, and especially general practitioners, must prescribe cautiously for their patients. Control through legislation of the sale of non-narcotic analgesics is worth serious consideration.

Clinical contact preceding suicide.

Of the 400 consecutive completed suicides investigated over a 5-year period, 114 (28.5%) who had consulted a doctor in the week preceding death were specifically reviewed and compared with those who did not. The study comprised an analysis of the medical history, the scene of death and a complete autopsy with histological and toxicological examination and the identification of features which occurred more frequently in this group when compared with other suicides not contacting their doctors. Suicide-associated factors include psychiatric illness (58.8%), deteriorating health (16.7%), and a loss of spouse (7.0%); all these features were manifested by this group of suicides more frequently than by those who made no clinical contact (P < 0.001). A pre-indication of suicidal intention was made by 45% of these patients. This feature, as with previous attempts, occurred more commonly in patients who consulted a doctor (P < 0.001). Drug overdose was the most common suicidal method chosen (50.9%) and anti-depressants predominated (35%); 78% of those who overdosed ingested prescribed drugs. Poisoning was more common in this group (P < 0.001). Half of the victims committed suicide within 24 hours following consultation; of these, 51% overdosed on drugs with 61% of them ingesting their prescribed drugs. Of these 114 cases, the final consultation in 43% was to collect more drugs. All suicidal threats should be taken seriously, and particular care should be taken in prescribing and dispensing medication which may be fatal in overdose.

Deaths of amateur scuba divers.

Four scuba diving deaths investigated by the Forensic Medicine Unit, University of Edinburgh Medical School, are reported. The pathological investigation of such deaths requires that a detailed history of the events prior to death is obtained and that the site of the accident is fully examined with underwater photographic recording where possible. The diving suits, breathing apparatus and other diving accessories also have to be examined carefully by experts and a complete autopsy with toxicological and histological examination is essential. The causes and mechanisms of death are discussed, as are the importance of special autopsy techniques and investigations. Possible interpretative problems are highlighted.

A review of completed suicides in the Lothian and Borders Region of Scotland (1987-1991).

A review of 400 completed suicides encountered during a 5-year period (January 1987-December 1991) in the Lothian and Borders Region of Scotland (LBRS) was conducted. The incidence was 9.4 per 100,000 with a M:F ratio of 2.4:1; the elderly had a significantly higher (P < 0.001) rate (9.9 per 100,000) compared to adolescents (3.3 per 100,000). Significantly (P < 0.001) more cases occurred in the rural communities. Overall, the peak incidence was in the 45- to 54-year age group. Drug overdose was the most common (39%) method used by both sexes and in both urban and rural communities; it was the first choice for virtually all age groups, and females exhibited greater preference. Analgesics and tricyclic antidepressants were the most common drugs used. Hanging (19.8%) was popular among the young and the elderly (> 64 years) suicides. Inhalation of car exhaust (13.3%) was a rural phenomenon and was common in the 25- to 54-year age group. Jumping from heights (9.8%) was more common in the urban areas; an increasing trend in the use of this method by females was possibly emerging. Drowning (8.3%) exhibited no particular pattern and the use of firearms was relatively uncommon (2.8%). This study and any subsequent assessment of socio-medical factors associated with completed suicide in this region should provide a basis for the formulation of preventive strategies. A continuous monitoring of the trends in the LBRS is necessary.